4 NURSING DOCUMENTATION IN CLINICAL PRACTICE There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle than to initiate a new order of thing. Machiavelli, The Prince

5 Nursing documentation in clinical practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell, Department of Nursing, Karolinska Institutet, Stockholm, Sweden Abstract The purpose of this study was to describe and analyse effects of a two-year comprehensive intervention concerning nursing documentation in patient records when using the VIPS model - a model designed to structure nursing documentation. Registered Nurses (RNs) from three acute care hospital wards participated in a two-year intervention programme, in addition, a fourth ward was used for comparison. The intervention consisted of education about nursing documentation in accordance with the VIPS model and organisational changes. To evaluate effects of the intervention patient records (n=269) were audited on three occasions: before the intervention, immediately after the intervention and three years after the intervention. For this purpose, a patient record audit instrument, the Cat-ch-Ing, was constructed and tested. The instrument aims at measuring both quantitatively and qualitatively to what extent the content of the nursing process is documented in the patient record. Inter-rater reliability, content validity, criterion-related validity, construct validity and internal consistency of the instrument were found to be satisfactory. A questionnaire was answered by 34 RNs to measure effects of the intervention. Their answer score was compared with the answer score of 343 RNs from other hospitals who had received a three-day course on nursing documentation based on the VIPS model. The questionnaire consisted of statements describing prerequisites and consequences about nursing documentation. Twenty RNs who had participated in the intervention programme also participated in focus group discussions on the effects of the intervention. The purpose was to describe their perceptions of and attitudes towards the effects of the intervention and to generate hypotheses for future research. The findings indicated a significant audit score increase in both quantity and quality of nursing documentation in the intervention wards immediately and three years after the intervention. The RNs who answered the questionnaire were largely in agreement about most of the specified consequences and prerequisites of nursing documentation. They perceived their documentation to increase patients safety and to be beneficial to RNs in their daily work. The use of the VIPS model was considered a facilitator of the documentation process. Statements in the focus group discussions were that the structured way of documenting nursing care made the RNs think more and think in a different way about their work with their patients. Two types of role changing for the RNs were reported: change from a medical technical focus to a more nursing expertise orientation and change from a hands on clinician to more of an administrator. This study demonstrates that training RNs to use a structured documentation system improves their record-keeping and care planning skills, however, such a system is not sufficient. There are likely other factors in the organisation of the clinical practice that influence the action of documenting nursing care in addition to lack of knowledge and practice. Keywords: Nursing documentation, record audit instrument, attitude, barriers to documentation, facilitators of documentation, focus groups, quality assurance ISBN Stockholm 2002

6 NURSING DOCUMENTATION IN CLINICAL PRACTICE ORIGINAL PAPERS This thesis is based on the following papers, which will be referred to by their Roman numerals: I Development of an audit instrument for nursing care plans in the patient record. Björvell C, Thorell-Ekstrand I, Wredling R. Quality in Health Care 2000,9,6-13. II Long-term increase in quality of nursing documentation: effects of a comprehensive intervention. Björvell C, Wredling R, Thorell-Ekstrand I. Scandinavian Journal of Caring Sciences 2002,16, III Prerequisites and consequences of nursing documentation in the patient record as perceived by a group of registered nurses. Björvell C, Wredling R, Thorell-Ekstrand I. Accepted for publication in Journal of Clinical Nursing, IV Registered nurses experiences of a comprehensive intervention using the VIPSmodel for nursing documentation: results of a focus group study. Björvell C, Wredling R, Thorell-Ekstrand I. Submitted, Reprints were made with the kind permission of the publishers.

10 INTRODUCTION There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. This is being accomplished through creating new systems, re-evaluating old systems and analysing reasons for poor compliance with legislation stipulating registered nurses (RNs ) obligation to document. One reason for the emphasis on nursing documentation may be the increasing need for secure and accurate transfer of patient-related information between different caregivers (Socialstyrelsen, 2000). The patient record is a principal source of information in which the nursing documentation of patient care is an essential component. This thesis originates from a need to prospectively analyse the effects of an intervention in an acute care setting concerning nursing documentation by the use of the VIPS model. This model, developed in 1991 by Ehnfors et al. is described in detail below. 9

11 BACKGROUND Nursing documentation a history In the past few decades the nursing profession has witnessed a change toward a more independent practice with explicit knowledge of nursing care. With the change has come the obligation to document not only the performed interventions - medical and nursing - but also the decision process, explaining why a specific nursing action has been prompted. During the 1980s and the early 1990s, major health-related organisations and some western countries began to develop standards, laws and regulations expressing that the nursing process (see below) should be used in nursing documentation. The World Health Organisation (1982), the International Council of Nursing (Clark, 1994), the American Joint Commission on Accreditation of Hospital Nursing Service Standards (1991) and the United Kingdom Central Council (1993) all promoted the use of the nursing process in nursing care. The Swedish law on this subject was passed in 1986 (SF 1985:562) and was further clarified specifically for nursing by the National Board of Health and Welfare in 1993 (SOSFS 1993:17). However, audit studies invariably describe evidence indicating that RNs have problems integrating the nursing process and care planning into their daily record keeping. In a review of 42 patient records, for instance, Davis et al. (1994) discovered that the assessment was poorly documented as were details of interventions. Moreover, psychological and social areas were not addressed and there were insufficient re-assessment and updating. In a study where RNs description of their nursing activities were compared with the content in the patient records (n=16) Hale et al. (1997) concluded that the records did not provide a complete picture of three important aspects of record keeping: patients needs for nursing intervention, interventions provided and effects of the interventions when compared with the patient s report. When investigating post-operative pain assessment, Briggs & Dean (1998) reported that it was poorly documented and that the nursing record differed from the patient s report. In a recent study, Martin et al. (1999) reviewed 80 patient records from a long-term care setting. The authors observed that while as many as 94% of the records included some kind of nursing assessment, the time in which the assessment had been completed in the records varied up to weeks and even months. Souder & O Sullivan (2000) found no nursing documentation on patients 10

12 cognitive status in 42 patient records, despite that a substantial number of the patients to whom the records referred were shown to have cognitive impairment when tested by standardised assessment tools. In Sweden, the development of written care plans has been slow and RNs have only recently begun to produce a more structured nursing documentation in the patient record. Although colleges of nursing in Sweden have prepared nursing students since the 1980s in how to prepare and use nursing care plans (see below) based on the nursing process, little of this knowledge is applied in the students clinical training on the wards. It has been suggested that nursing students are not sufficiently supported in their clinical practice when it comes to writing and using care plans (Thorell-Ekstrand & Björvell, 1994). One reason for this lack of support may be that clinicians with earlier education are not trained to give care from a conscious nursing process model or to write care plans prospectively. Because the nursing education was prolonged and integrated into the university system as late as 1993, problem solving skills and systematic thinking may be in general clinical use in the future. Rather than documenting the prospective planning of nursing care, the tradition among RNs is still to document the given care retrospectively, which is primarily the medical care ordered by the physician. Ehnfors & Smedby (1993) showed that 90% of the audited patient records (n=106) lacked identified nursing problems, goals and nursing discharge notes. In two thirds of the records, planned interventions were missing. In 1996, Nordström & Gardulf asserted that the nursing assessment was insufficiently described in 60% of the audited records (n=380); only 10% contained identified nursing problems and goals and less than 45% of the records contained planned nursing interventions. Still in 1999, Ehrenberg & Ehnfors (1999a) showed that only one of 120 patient records contained a comprehensive description of a patient problem, as prescribed by Swedish law. Several Swedish studies described nursing record content with regard to specific risk assessments. Gunningberg et al. (2000), for example, described that only two of ten records on patients admitted for hospital care with pressure ulcer comprised notes on pressure ulcers recorded on admission to the ward. Gunningberg et al. (2001) later described that none of the records referring to 55 orthopaedic patients admitted with hip fracture and with a mean age of 82 years contained information on risk assessment for pressure ulcer: skin observation, food and fluid intake, shear and friction, hygiene and moisture or patient education). Udén et al. (1999) showed that after an intervention aimed to improve the documentation of risk factors concerning patient falls, the recording of assessments of risk factors increased to include 96% 11

13 of the patient records (n=319), though only 10% were re-assessed. Before the intervention, there was no documentation regarding risk factors. In an audit study (Wärn-Hede et al, unpublished data) on documentation of nutritional risk factors in geriatric patients, 49 of 52 records contained less than 50% of information considered necessary for adequate documentation. Whether assessments have been made and simply not documented is another research issue. However, there are also studies demonstrating increasingly good nursing documentation. Fagrell et al. (1998) found that 119 (71%) of 163 nursing home records included an individual care plan. In other parts of Scandinavia, Stokke & Kalfoss (1999) reported from a Norwegian audit study comprising 55 patient records that 62% had a nursing care plan with nursing diagnoses and a goal and only 18% lacked nursing diagnoses and planned interventions. Still, the authors conclude that the Norwegian Board of Health guidelines are not fully met. In Denmark, Adamsen & Tewes (2000) found that the nurse documented in the patient record only 31% of the problems experienced by the patients. One further reason for the slow development and improvement of nursing documentation and care planning in Sweden in addition to traditions is probably the previous lack of a uniform and unambiguous system. Administrative changes within nursing During the 1960s and 1970s, the healthcare system in Sweden experienced a period of expansion. The major change was that the industrial principals of assembly lines influenced the organisation of nursing care on the hospital wards and the task allocation system was introduced (Gardell et al.,1979). This meant that each RN focused on her tasks and not on individual patients. One RN would deliver medication to all patients while another RN would give all injections, etc. This way each patient would have a number of short encounters with a large number of persons and the patient became a gallbladder, a blood-pressure check, an iv drip, and so on. It became difficult for the RNs to obtain a complete picture of the individual patient s situation and his or her possible reasons for specific nursing needs. In the early 1970s, the kardex system was introduced in all hospital wards across Sweden. It was a means for temporary documentation, with the purpose of providing a quick overview of the patients admitted to the ward and the fragmented care that was delivered within the task allocation system. The advantage with the kardex system was the good overview it provided. 12

14 The disadvantage was that the documentation did not give a complete picture of the patient s nursing needs because the notes were written in pencil and erased when the intervention was completed or the patient s condition had improved. During the 1980s, the structure of the kardex system changed. The text was now written in ink, the papers were archived as a permanent record and the papers were repeatedly adjusted to allow documentation by the nursing process (Thorell-Ekstrand & Wallstedt, 1986). However, the clinical experience evidenced that the papers rarely were used the way they were constructed to be used because of the RNs lack of tradition to work using the nursing process. The kardex system also necessitated the use of local abbreviations because of lack of space, with the subsequent risk of misunderstanding and individual interpretations by the persons reading the text. In connection with the new legal requirements in 1986 and the arrival of the VIPS model (Ehnfors et al., 1991), it became evident that the kardex system no longer fulfilled the requirements of a patient record paper. New paper systems, with space for documenting a complete patient situation, became common and the nursing papers were moved from the kardex and joined with the rest of the patient record to further increase the complete picture of the patient s needs of treatment and care. Changes within the acute health care system Over the past years the Swedish health care system has experienced general changes as a result of cost cuttings and reorganisations (Socialstyrelsen, 2000; Kajermo et al., 2000; Needleman et al., 2002). Between 1992 and 2000, the mean patient length of stay in hospital decreased by 21% and the patient turnover rate increased. Although the number of hospital beds decreased by 45%, the number of hospital days only decreased by 30%. This means that the bed occupancy rate increased by 30% while at the same time staffing was cut by 24% (Petterson, 1997; Lanstingsförbundet, 2002). Furthermore, the increase in medical technology adds new tasks and new demands on all health care professionals. A work environment with high patient turnover and where patients and nurses are moved constantly between settings makes it difficult for the RNs to make necessary assessments and to keep care plans up-to-date (Davis et al., 1994; O'Connell, 1998). It is possible that the shorter the patient s hospital stay, the more difficult it becomes for the RN to identify the process of care. If the RN then is not trained, or rather, if it is not part of 13

15 her professional tradition to use systematic, problem- and goal-oriented thinking, the risk is eminent that she will miss important aspects of the patient s needs because the time he or she has to observe the patient is too short. Benefits of nursing documentation The RN has a paramount responsibility to foreword information about the patient s needs and treatment to other health care professionals. Traditionally, this has been done verbally. However, today the information on the patient s condition, care and treatment has become more complex and the amount of individuals in need of this information has increased. Information technology has made its entrance into the health care system whereby verbal transfer of information is becoming obsolete. The main benefit of documentation is improvement of the structured communication between healthcare professionals to ensure the continuity of individually planned patient care. Without an individualised care plan that is closely followed, nursing care tends to become fragmentary, being based predominantly on institutional routine and schedules. The care plan defines the focus of nursing care not only to the nursing staff but also to the patients and their relatives (Carpenito, 1997). By documenting the agreement between patients and RNs, an opportunity is provided for the patients to participate in the decision-making process of their own care (Kramer, 1972; Jairath, 1994). Moreover, the documentation of expert nursing provides an important source of knowledge to the novice RN and a potential motivating force for the further development of nursing theory (Meleis, 1997). The care plan yields criteria for reviewing and evaluating care, as well as financial reimbursement (Carpenito, 1997) and staffing. In an investigation of dimensions of nursing practice (Bradley, 1982), 137 RNs were asked to rate 28 items describing nursing actions on a four-point scale ranging from essential to slightly important. Results showed that the action of Designing care plans in collaboration with the patient received a mean score of 3.25, which ranked as the ninth most important nursing action. The action Use the nursing process as a basis for interventions received a mean score of 3.24, which ranked eleventh. 14

16 Barriers to nursing documentation RNs perception of facilitating and inhibiting factors in relation to their nursing documentation has been described in some articles internationally as well as in Sweden. Tapp (1990) interviewed 14 RNs with the aim of identifying RNs perception of inhibitors and facilitators to their documentation. The participants in the study indicated that the lack of a distinct professional identity and language in nursing and a redundancy of forms result in inaccurate and devalued documentation of nursing care. Tapp also reported other inhibitors, such as lack of time, space and place. Facilitating issues described were the use of a theoretical framework, positive reinforcement by supervisors and change in the condition of the patient. Howse & Bailey (1992) performed a qualitative case study where four RNs were interviewed about underlying causes of antipathy toward documentation. The authors reported several barriers to documentation, including inadequate charting systems, lack of value and use for record entries, environmental disruptions, inaccessibility of the record, lack of time to document, a work group norm of a negative attitude to documentation and the perceived difficulty in phrasing correctly. Heartfield (1996) presented a discourse analysis on nursing and its documentation in which she noted that RNs have a resistance to becoming visible with their knowledge. Hence, their documentation consists of passive descriptions of observations and responses, unlike other professions who write about their judgement and examinations. This, Heartfield claimed, removes the RN from visibility and therefore from examination and comparison, a process that helps to conserve the prevailing mythical image of the nurse-patient relationship. Allen (1998) presented results from an ethnographic study with 10 months fieldwork and 57 interviews. She concluded that the RNs attitudes were contradictory in the sense that they valued the nursing process as a means of professionalism, but that they found it difficult to bring it to terms with their work on the wards. She raised the argument that the nursing process is based on a model of a one-to-one nurse-patient relationship, whereas RNs in most hospital realities have multiple patient assignments. The findings concur with five Swedish studies, three of which were scientifically published. In a questionnaire study (Ehnfors, 1993), different areas of barriers to documentation were identified in 138 open answers. In all, seven areas were distinguished: ward in a process of change, lack of crucial content, lack of knowledge, lack of interest, lack of time and resources, lack of a uniform documentation structure and short care episodes. An interview with nine RNs (Jerlock & Segesten, 1994) identified, among other things, lack of knowledge of the nursing process, a negative attitude toward change, inability to see the 15

17 benefits of nursing documentation and difficulty in formulating thoughts and what to write. In another study, a number of inhibitors like lack of knowledge, lack of time, lack of consistent record systems, lack of continuity and lack of motivation to write) were described in open answer questions from 31 RNs (Larsen et al., 1995). Törnkvist et al.(1997) reported on the opinions held by 164 district nurses regarding their documentation and barriers they experienced. The nurses described such barriers as lack of a consistent record system and routines, lack of time, lack of knowledge about what should be documented, environmentally related conditions such as inadequate computers, interruptions and lack of support from supervisors and colleagues. In yet another study, Ehrenberg (2001) asked 165 RNs in nursing homes about factors that they felt constrain nursing documentation. The author described lack of time, lack of knowledge, organisational obstacles, difficulty in writing and inappropriate forms. Difficulties are described on the individual level as well as on the administrativeorganisational level. Laws and regulations in Sweden The purpose of the patient record is stipulated in the Patient Record Act (SFS 1985:562). First and foremost, the purpose of the record is to be a tool of reference for healthcare professionals, as well as a possible source of information to the patient. Second, it should be an instrument for quality assurance and a reference for legal purposes, and third, the patient record should be a possible source for research and development. The act specifies the need to structure the content in the patient record, which implicitly has been interpreted by the Swedish National Board of Health and Welfare (SOSF 1993:17) as an application of the nursing process: assessment and collection of patient data, analysis and definition of goal, planning, prioritisation and implementation of interventions and evaluation of effects. When the Patient Record Act (SFS 1985:562) came into effect, it implied a major change for RNs, who now became obligated by law to document nursing care. In the years to follow, the Swedish National Board of Health and Welfare accentuated this obligation in their regulations concerning nursing in somatic and primary healthcare (SOSFS 1993:17) and stated more precise directions in their clarification of the law (SOSFS 1993:20). Further instructions on the importance of accurate and careful record keeping were prescribed in their 16

18 regulations concerning quality assurance in healthcare (SOSFS 1996:24) and in their regulations on transfer of information between healthcare institutions (SOSFS 1996:32). Poor documentation is an indication that further investigations are needed to judge whether the given care is less than optimal. Audit instruments for patient records are therefore needed to identify the quality of assessment, the structure and the plan for the patient's care. Instruments are also needed to evaluate the effects of interventions aimed to improve the documentation. Auditing patient records The audit of patient records is performed for several reasons. The most common reason is that the audit is part of an ongoing process of quality improvement. A clinic may have agreed to document in a certain way, possibly with a minimum data set as a standard, or it wants to evaluate specific criteria for quality healthcare (Shaw, 1990; Honnas & Zlotnick, 1995; Griffiths & Hutchings, 1999). There is evidence that a continuously performed audit of patient records, combined with discussions about improvements, is one way to improve the quality of the records and to change certain behaviours of healthcare professionals (Gabbay et al., 1990; Heath, 199; Mashru & Lant, 1997). Another reason for auditing documentation is that it makes comparisons possible over time and between wards or hospitals, provided that a reliable audit instrument is used to put a numerical value on the written content (Fagrell et al., 1998; Hansebo et al., 1999). The audit is also used to evaluate the effects of quality management (Webb & Pontin, 1997) by identifying the professional strengths to be maintained and the weaknesses to be addressed and corrected. Craig (1987) reported that RNs were able to obtain a better understanding of what was expected of them when using their audit tool in recording and patient care, as well as in the areas on which they specifically needed to concentrate for improvement. It is of importance to differentiate between record auditing for the sake of measuring the quality of record keeping and record auditing for the sake of measuring the quality of given care. The patient records do not necessarily reflect the reality of the given care, an issue that has received some criticism in the literature (Sparrow & Robinson, 1992; McElroy et al., 1995). However, well written records may be seen as a step toward a process of quality assurance in the sense that it functions as a structured element in nursing care. Donabedian (1988) carefully stressed that good structure only increases the likelihood of a good process in 17

19 the actual care given and that the correlation between process and outcome has yet to be shown. Whether better documentation can also influence and improve patient care is another question, but is beyond the scope of this thesis. Previously existing audit instruments A review of the literature indicates that two Swedish audit instruments have been developed earlier, one by Ehnfors & Smedby, (1993) and the other by Gardulf & Nordström (1996). Both instruments are based on the nursing process and evaluate the record in its quantitative aspect: is there documentation for each function or not? In addition, Ehnfors & Smedby, (1993) evaluates for each patient problem the flow of information in accordance with the nursing process. Consequently, neither of the instruments includes a qualitative evaluation of the written content in the sense of the amount of information, wording, pertinence, etc. A number of other audit instruments described in international journals (Vandelt & Ager, 1974; Ventura, 1980; Goldstone et al., 1983; Manfredi, 1986; Harvey, 1991; Sparrow & Robinson, 1992) were also not optimal with respect to the quality and quantity aspects of auditing Swedish patient records. CONCEPTUAL FRAMEWORK The nursing process model and patient care plans The nursing process model has its roots in general systems theory (GST) (Andersson- Segesten, 1989; Barnum, 1994), which became the basis for scientific inquiry in the 1950s and 1960s after it had been introduced by von Bertalanffy (1968). The nursing process model was first described by Orlando in 1961 (in Meleis, 1997, p. 344) and later by Yura & Walsh in 1967 (1988) as a structured, problem-solving approach to nursing practice and nursing documentation. The model originally consisted of four steps: assessment, planning, implementation and evaluation. In a later version, a fifth step, nursing diagnosis, was added. Today, these five steps are the commonly accepted components of the model (McFarland & McFarlane, 1993). Judging from the nursing literature, it is evident that the nursing process model is a central and widely accepted concept, both for nursing practice and for nursing documentation (Meleis, 1997). The nursing process is an orderly, systematic manner of determining the client s health status, specifying problems defined as alterations in human needs fulfilment, making plans to solve them, initiating and 18

20 implementing the plan, and evaluating the extent to which the plan was effective in promoting optimum wellness and resolving the problems identified (Yura & Walsh, 1988, p.1). Although the model is based on a scientific method of investigation and goal-oriented actions, it is considerably more than just a systematic problem solving technique. The primary purpose of the model is to secure individualised nursing care to the individual patient as opposed to generalised care based on routines. The nursing process is described as a confirming interaction where the caregiver confirms, in the encounter with the patient, what he or she perceives to be the patient s care needs (Yura & Walsh, 1988). One purpose with the nursing process is to help patients become actively involved in their own care and to create a platform for the RN to collect information about the patients individual need of care. A conclusion drawn from the WHO project (Ashworth et al., 1987) was that it takes more than the medical diagnosis system to describe the patient s needs for nursing care. The patient s medical record contains important information; however, it is not sufficient to provide the RN with the data needed to give individually based nursing care. Critique of the nursing process model Although the nursing process model permeates nursing internationally, critique has been raised over the years. White (1993), for instance, refers to a number of reports and studies indicating that the nursing process, having a scientific reductionistic approach and depicting a male way of analysing problems, is ill-fitted for a profession that, by tradition, is mainly intuitive and subjective and predominantly female. White also raised the point that the nursing process cannot stand by itself. Rather, it is a tool to be used to implement a nursing model or philosophy into practice. The RN must also have a belief or philosophy that directs his or her assessment, planning and delivery of care. Kirkevold (2000) confirmed that the model has been criticised for being a scientific model that lacks consideration of the intuitive aspects of nursing, reducing the patient to a set of problems. She also noted that the model is now gaining ground again because of the systematic and logical structures that the electronic patient record demands. Mason & Attree (1997) concluded from their literature review that through the research on nursing diagnosis, the nursing process has been re-established as a primarily clinical rather than educational process. In the future, the nursing process may be considered a grand theory 19

6 Quality in Health Care 2000;9:6 13 Papers Development of an audit instrument for nursing care plans in the patient record C Björvell, I Thorell-Ekstrand, R Wredling Division of Research at Karolinska

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